Rapid Adjustment of Clinical Decision Support in Response to Updated Recommendations for Palivizumab Eligibility

Jeremy Michel; Levon H. Utidjian; Dean Karavite; Annique Hogan; Mark J. Ramos; Jeffrey Miller; Richard N. Shiffman; Robert W. Grundmeier

doi:10.4338/ACI-2016-10-RA-0173

Applied Clinical Informatics, Inhaltsverzeichnis

Appl Clin Inform 2017; 08(02): 581-592
DOI: 10.4338/ACI-2016-10-RA-0173

Research Article

Schattauer GmbH

Rapid Adjustment of Clinical Decision Support in Response to Updated Recommendations for Palivizumab Eligibility

Autoren

Jeremy Michel

¹Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania

²Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Levon H. Utidjian

¹Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania

²Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Dean Karavite

²Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Annique Hogan

¹Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
Mark J. Ramos

²Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Jeffrey Miller

²Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Richard N. Shiffman

³Department of Pediatrics

⁴Yale Center for Medical Informatics, Yale University, New Haven, Connecticut
Robert W. Grundmeier

¹Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania

²Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Abstract

Summary

Background: Palivizumab is effective at reducing hospitalizations due to respiratory syncytial virus among high-risk children, but is indicated for a small population. Identification of patients eligible to receive palivizumab is labor-intensive and error-prone. To support patient identification we developed Clinical Decision Support (CDS) based on published recommendations in 2012. This CDS was developed using a systematic process, which directly linked computer code to a recommendation’s narrative text. In 2014, updated recommendations were published, which changed several key criteria used to determine eligible patients.

Objective: Assess the effort required to update CDS in response to new palivizumab recommendations and identify factors that impacted these efforts.

Methods: We reviewed the updated American Academy of Pediatrics (AAP) policy statement from Aug 2014 and identified areas of divergence from the prior publication. We modified the CDS to account for each difference. We recorded time spent on each activity to approximate the total effort required to update the CDS.

Results: Of the 15 recommendations in the initial policy statement, 7 required updating. The CDS update was completed in 11 person-hours. Comparison of old and new recommendations was facilitated by the AAP policy statement structure and required 3 hours. Validation of the revised logic required 2 hours by a clinical domain expert. An informaticist required 3 hours to update and test the CDS. This included adding 24 lines and deleting 37 lines of code. Updating relevant data queries took an additional 3 hours and involved 10 edits.

Conclusion: We quickly adapted CDS in response to changes in recommendations for palivizumab administration. The consistent AAP policy statement structure and the link we developed between these statements and the CDS rules facilitated our efforts. We recommend that CDS implementers establish linkages between published narrative recommendations and their executable rules to facilitate maintenance efforts.

Citation: Michel J, Utidjian LH, Karavite D, Hogan A, Ramos MJ, Miller J, Shiffman RN, Grundmeier RW. Rapid adjustment of clinical decision support in response to updated recommendations for palivizumab eligibility. Appl Clin Inform 2017; 8: 581–592 https://doi.org/10.4338/ACI-2016-10-RA-0173

Keywords

Clinical decision support - pediatrics - clinical practice guideline - use - administration and maintenance of clinical information systems - ambulatory care - primary care

Volltext

Referenzen

References
1 Sucher JF, Moore FA, Todd SR, Sailors RM, McKinley BA. Computerized clinical decision support: a technology to implement and validate evidence based guidelines. J Trauma 2008; 64 (02) 520-537.
2 Damiani G, Pinnarelli L, Colosimo SC, Almiento R, Sicuro L, Galasso R, Sommella L, Ricciardi W. The effectiveness of computerized clinical guidelines in the process of care: a systematic review. BMC Health Serv Res 2010; 10: 2.
3 Latoszek-Berendsen A, Tange H, van den Herik HJ, Hasman A. From clinical practice guidelines to computer-interpretable guidelines. A literature overview. Methods Inf Med 2010; 49 (06) 550-570.
4 Forrest CB, Fiks AG, Bailey LC, Localio R, Grundmeier RW, Richards T, Karavite DJ, Elden L, Alessandrini EA. Improving Adherence to Otitis Media Guidelines With Clinical Decision Support and Physician Feedback. Pediatrics. 2013
5 American Academy of Pediatrics.. From the American Academy of Pediatrics: Policy statements--Modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Pediatrics 2009; 124 (06) 1694-1701.
6 Utidjian LH, Hogan A, Michel J, Localio AR, Karavite D, Song L, Ramos MJ, Fiks AG, Lorch S, Grund-meier RW. Clinical Decision Support and Palivizumab: A Means to Protect from Respiratory Syncytial Virus. Appl Clin Inform 2015; 6 (04) 769-784.
7 GoodRx. Palivizumab Prics and Palivizumab Coupons. 2016 [cited 2016 June 11]; Available from: http://www.goodrx.com/palivizumab?drug-name=palivizumab
8 Ambrose CS, McLaurin KK. The Medicaid Cost of Palivizumab. J Pediatric Infect Dis Soc 2015; 4 (01) 83-84.
9 Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics 2014; 134 (Suppl. 02) e620-e638.
10 Dixon MMG, Shiffman RN. GuideLines Into DEcision Support (GLIDES). Yale University: Yale University; 2013
11 Shiffman RN, Michel G, Essaihi A, Thornquist E. Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation. J Am Med Inform Assoc 2004; 11 (05) 418-426.
12 Shiffman RN, Karras BT, Agrawal A, Chen R, Marenco L, Nath S. GEM: A Proposal for a More Comprehensive Guideline Document Model Using XML. J Am Med Inform Assoc 2000; 7: 11.
13 Karavite D. GEM cut representation of the Policy Statement—Modified Recommendations for Use of Palivizumab for Prevention of Respiratory Syncytial Virus Infections. Center for Biomedical Informatics. 2010
14 Proctor M. Drools.A Rule Engine for Complex Event Processing. In: Schürr A, Varró D, Varró G. editors. Applications of Graph Transformations with Industrial Relevance: 4th International Symposium, AGTIVE 2011, Budapest, Hungary, October 4–7, 2011. Revised Selected and Invited Papers Berlin, Heidelberg: Springer Berlin Heidelberg; 2012. p. 2.
15 GitHub. GitHub Inc.; 2016 [cited 2016]; Available from: https://www.github.com
16 Zembles TN, Gaertner KM, Gutzeit MF, Willoughby RE. Implementation of American Academy of Pediatrics guidelines for palivizumab prophylaxis in a pediatric hospital. Am J Health Syst Pharm 2016; 73 (06) 405-408.
17 Wright A, Sittig DF, Ash JS, Bates DW, Feblowitz J, Fraser G, Maviglia SM, McMullen C, Nichol WP, Pang JE, Starmer J, Middleton B. Governance for clinical decision support: case studies and recommended practices from leading institutions. J Am Med Inform Assoc 2011; 18 (02) 187-194.
18 Ash JS, Sittig DF, Dykstra R, Wright A, McMullen C, Richardson J, Middleton B. Identifying best practices for clinical decision support and knowledge management in the field. Stud Health Technol Inform 2010; 160 Pt 2 806-810.
19 Peleg M. Computer-interpretable clinical guidelines: a methodological review. J Biomed Inform 2013; 46 (04) 744-763.
20 CMS. Selecting a Development Approach. In: Services OoI, editor.: Center for Medicare and Medicaid Service (CMS); 2008 p. 1-10.
21 Shah H, Allard RD, Enberg R, Krishnan G, Williams P, Nadkarni PM. Requirements for guidelines systems: implementation challenges and lessons from existing software-engineering efforts. BMC Med Inform Decis Mak. 2012: 12
22 Boehm B. A spiral model of software development and enhancement. SIGSOFT Softw Eng Notes 1986; 11 (04) 14-24.
23 Sittig DF, Wright A, Osheroff JA, Middleton B, Teich JM, Ash JS, Campbell E, Bates DW. Grand challenges in clinical decision support. J Biomed Inform 2008; 41 (02) 387-392.
24 Sittig DF, Wright A, Simonaitis L, Carpenter JD, Allen GO, Doebbeling BN, Sirajuddin AM, Ash JS, Middleton B. The state of the art in clinical knowledge management: an inventory of tools and techniques. Int J Med Inform 2010; 79 (01) 44-57.
25 Wright A, Ash JS, Erickson JL, Wasserman J, Bunce A, Stanescu A, St Hilaire D, Panzenhagen M, Gebhardt E, McMullen C, Middleton B, Sittig DF. A qualitative study of the activities performed by people involved in clinical decision support: recommended practices for success. J Am Med Inform Assoc 2014; 21 (03) 464-472.
26 Hulse NC, Galland J, Borsato EP. Evolution in clinical knowledge management strategy at Intermountain Healthcare. AMIA Annu Symp Proc 2012; 2012: 390-399.
27 Grandi F, Mandreoli F, Martoglia R. Efficient management of multi-version clinical guidelines. J Biomed Inform 2012; 45 (06) 1120-1136.
28 Pediatrics AAo. Errata. Pediatrics 2014; 134 (06) 1221.
29 Grindeland CJ, Mauriello CT, Leedahl DD, Richter LM, Meyer AC. Association Between Updated Guideline-Based Palivizumab Administration and Hospitalizations for Respiratory Syncytial Virus Infections. Pediatr Infect Dis J. 2016 Epub 2016/04/15.
30 McLaurin KK, Chatterjee A, Makari D. Modeling the Potential Impact of the 2014 American Academy of Pediatrics Respiratory Syncytial Virus Prophylaxis Guidance on Preterm Infant RSV Outcomes. Infect Dis Ther 2015 Epub 2015/10/27.
31 Shiffman RN, Dixon J, Brandt C, Essaihi A, Hsiao A, Michel G, O’Connell R. The GuideLine Implementability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation. BMC Med Inform Decis Mak 2005; 5 (23) 1-8.
32 Hajizadeh N, Kashyap N, Michel G, Shiffman RN. GEM at 10: A decade’s experience with the Guideline Elements Model. AMIA Annu Symp Proc 2011: 520-529.
33 Shiffman RN, Michel G, Rosenfeld RM, Davidson C. Building better guidelines with BRIDGE-Wiz: development and evaluation of a software assistant to promote clarity, transparency, and implementability. J Am Med Inform Assoc 2012; 19 (01) 94-101.